A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?

Position the client prone and have the respiratory therapist perform postural drainage.

Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.

Increase oxygen to 70%.

Switch oxygen to a nonrebreather mask.

Answer and Explanation

The Correct Answer is B

A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.

B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).

C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.

D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.

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Correct Answer is D

Explanation

A. A 60-year-old client with gastritis:

Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.

B. A 20-year-old client with a closed tibia fracture:

A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.

C. A 55-year-old client taking an ACE inhibitor:

ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.

D. A 35-year-old client receiving chemotherapy:

Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.

A. Intact skin with nonblanchable redness, painful,warm, soft localized area over a bony prominence B. Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising C. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling D. Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling

Correct Answer is A

Explanation

A. Intact skin with nonblanchable redness, painful, warm, soft localized area over a bony prominence

Stage 1 pressure injuries are characterized by intact skin with nonblanchable redness over a localized area, typically over a bony prominence like the sacrum, heel, or elbow. The skin may feel painful, warm, and soft to the touch. Nonblanchable redness means that when pressure is applied to the area, the redness does not fade or blanch (turn white). This stage indicates that tissue damage has occurred, but the skin is still intact.

B. Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising: This description is more indicative of a Stage 2 pressure injury, which involves partial-thickness skin loss with an intact or ruptured blister. The wound bed is usually pink or red, and there is no sloughing or bruising.

C. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling: This description corresponds to a Stage 3 or Stage 4 pressure injury. Stage 3 involves full-thickness tissue loss with visible subcutaneous fat but no bone, tendon, or muscle exposed. Stage 4 involves extensive tissue loss with exposure of bone, tendon, or muscle. Both stages may include slough (yellow or white tissue) and black eschar (hard, necrotic tissue), along with undermining (tissue destruction under intact skin edges) and tunneling (narrow passageways extending from the wound).

D. Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling: This description also corresponds to a Stage 3 pressure injury, as it involves full-thickness tissue loss with visible subcutaneous fat. The mention of possible undermining and tunneling further suggests a Stage 3 pressure injury.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for several clients. Which of the following clients is most prone to skin infections?

Correct Answer is D

Explanation

What would be considered early signs/symptoms of pressure injury (Stage 1)?

Correct Answer is A

Explanation

A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen?

A nurse is assisting in identifying clients on the medical surgical floor with skin problems. Which of the following are most likely to become chronic wounds?

A nurse is giving a preoperative patient a dose of famotidine ( Pepcid). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response by the nurse is best?

A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?

A nurse assesses a patient who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.)

A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)

A nurse is reviewing the client's medical record in the presurgical holding area. Which of the following places the client at risk for a surgical site infection?

What is the common factor for etiology and pathophysiology of folliculitis, furuncles, and carbuncles?